Academic Article, March 2026

จากครรภ์ไข่ปลาอุกสู่มะเร็งเนื้อรก

Chanokrak Sriwattanapong,M.D./ Asst.Prof. Yudthadej Thaweekul,M.D.
Department of Obstetrics and Gynaecology, Faculty of Medicine, Thammasat University

          Hydatidiform mole, commonly termed molar pregnancy, constitutes an aberrant gestational state resulting from fertilization anomalies, with documented occurrence in approximately 2 per 1,000 pregnancies.¹ Although the incidence remains modest, clinical significance is substantial due to the absence of viable pregnancy development and the associated risk of transformation to malignancy which defined as “Gestational trophoblastic neoplasia (GTN)”.²

          Modern therapeutic approaches and systematic surveillance protocols for gestational trophoblastic disease (GTD), encompassing both molar pregnancy and GTN, yield highly favorable cure rates.^2,3 Nevertheless, insufficient patient comprehension regarding post-treatment monitoring requirements continues to pose clinical challenges. This review provides detailed examination of molar pregnancy pathogenesis, GTN development patterns, and contemporary evidence-based management strategies.

Pathophysiology and Disease Classification

          Molar pregnancy develops secondary to chromosomal aberrations during fertilization, with classification into two principal categories: complete and partial moles. Complete molar gestation demonstrates absence of embryonic tissue, presenting exclusively with abnormal placental proliferation, and demonstrates elevated GTN progression risk. Partial molar gestation may exhibit abnormal embryonic components concurrent with placental abnormalities, demonstrating reduced malignant transformation potential.^1,6

          Notable risk determinants include extremes of maternal age. Women exceeding 40 years or below 20 years demonstrate approximately 8-10 times higher risk relative to women in optimal reproductive years.^1,2 Furthermore, antecedent molar pregnancy constitutes an established recurrence risk factor.⁶

Clinical Manifestations and Diagnostic Approach

          Women with molar pregnancy characteristically present with abnormal vaginal bleeding during early gestation. Expulsion of grape-cluster appearing vesicular tissue may occur. Additionally, hyperemesis gravidarum exceeding typical pregnancy-related nausea may develop, correlating with markedly elevated hCG concentrations.^1,2

          Diagnostic evaluation incorporates transvaginal ultrasonography combined with serum hCG quantification, which demonstrates substantial elevation beyond normal gestational values.^1,3 Histopathological analysis of evacuated material establishes definitive diagnosis.⁶

Primary Management and Monitoring Protocols

          Following molar pregnancy diagnosis, two principal therapeutic options exist:

1. Suction evacuation constitutes the predominant approach for women desiring fertility preservation. This technique utilizes vacuum aspiration for uterine cavity evacuation of abnormal tissue.^1,3

2. Hysterectomy provides appropriate definitive therapy for women with completed reproductive plans.³

          Independent of selected therapeutic modality, serial hCG surveillance represents fundamental post-treatment monitoring. Patients require hCG assessment at 1-2 week increments until undetectable values are achieved^3,5, generally necessitating 4-5 monitoring appointments. Surveillance protocol non-adherence persists as a significant clinical concern, potentially resulting in delayed GTN identification.

Association Between Molar Pregnancy and GTN Development

          GTN may emerge after molar evacuation. Clinical suspicion warrants elevation when hCG demonstrates plateau or inadequate decline post-treatment, or when hCG elevation recurs following previous normalization.^2,3 However, GTN can follow other types of pregnancy, but the incidence is rare.

          Upon GTN diagnosis, modern chemotherapeutic approaches achieve cure in most cases across all disease stages. These exceptional outcomes reflect the marked sensitivity of GTN to chemotherapeutic agents.

Gestational Trophoblastic Neoplasia Treatment Strategies

          Chemotherapy constitutes primary GTN therapy. Treatment regimen selection utilizes FIGO prognostic scoring for risk stratification into low-risk versus high-risk categories. Individualized chemotherapy protocols minimize toxicity while maintaining superior cure rates.^4,5

          Throughout treatment, reliable contraception remains mandatory. Highly effective methods including combined hormonal contraceptives or consistent barrier methods are essential for pregnancy prevention during therapy. Concurrent pregnancy would generate physiological hCG elevation, thereby obscuring disease monitoring and therapeutic response evaluation.^5,6

Subsequent Reproductive Potential

          Following successful molar pregnancy or GTN treatment, most women achieve normal gestations with outcomes equivalent to general population statistics.^1,2 However, women experiencing recurrent molar pregnancy (≥2 occurrences) warrant specialized trophoblastic disease consultation for optimized future pregnancy planning.

Conclusion

          Molar pregnancy represents an abnormal gestational condition stemming from fertilization defects, carrying potential for GTN progression. Nevertheless, contemporary evidence-based treatment protocols combined with systematic monitoring achieve remarkably favorable cure rates. Treatment success fundamentally depends upon patient comprehension and surveillance protocol adherence with scheduled hCG monitoring. Most patients can anticipate successful subsequent pregnancies with normal outcomes. Thorough patient education addressing disease pathophysiology and monitoring protocol importance constitutes an essential component of optimal clinical management.

References

1. Berkowitz RS, Goldstein DP. Clinical practice. Molar pregnancy. N Engl J Med. 2009;360:1639-1645.
2. Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. Lancet. 2010;376:717-729.
3. Lurain JR. Gestational trophoblastic disease I. Am J Obstet Gynecol. 2010;203:531-539.
4. FIGO Oncology Committee. FIGO staging for gestational trophoblastic neoplasia. Int J Gynaecol Obstet. 2002;77:285-287.
5. National Comprehensive Cancer Network. Gestational Trophoblastic Neoplasia (NCCN Guidelines®) Version 2.2026. National Comprehensive Cancer Network, Inc.; 2025.
6. Lertkhachonsuk R, Lertkhachonsuk A. Gestational Trophoblastic Disease. 1st ed. Bangkok: Concept Medicus; 2019.